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Role of Hospital Surfaces in the Spread of Emerging HA Pathogens:C. difficile, Norovirus, Acinetobacter
William A. Rutala, Ph.D., M.P.H.Director, Hospital Epidemiology, Occupational Health and Safety
Program, University of North Carolina (UNC) Health Care
Professor of Medicine, UNC at Chapel Hill, NC, USA
Disclosure: ASP and Clorox
Disclosure
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Role of Surfaces in Spread of HA Pathogens
Factors that facilitate environmental transmission Acinetobacter
Norovirus
C. difficile
The Role of the Environment in Disease Transmission
Over the past decade there has been a growing appreciation that environmental contamination makes a contribution to HAI with MRSA, VRE, Acinetobacter, norovirus, and C. difficile
Surface disinfection practices are currently not effective in eliminating environmental contamination
Some organisms have better ability to persist in the inanimate environment than others (e.g. C. difficile, MRSA, VRE, Acinetobacter)
Inadequate terminal cleaning of rooms occupied by patients with MDR pathogens places the next patients in these rooms at increased risk of acquiring these organisms
KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION
MRSA
VRE
Clostridium difficile
Acinetobacter spp.
Norovirus
Rotavirus
SARS
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FACTORS THAT FACILITATE ENVIRONMENTAL TRANSMISSION
Survive in the environment for days to weeks to months
Frequently contaminate the environmental surfaces in rooms of colonized or infected patients
Transiently colonize the hands of healthcare personnel
Transmitted by healthcare personnel
Cause outbreaks in which environmental transmission was deemed to play a role
Improved surface cleaning/disinfection reduces disease incidence
Admission to a room previously occupied by a patient with the pathogen of interest is a risk factor for disease for the newly admitted patient to develop colonization/infection
TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT
Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.
KEY PATHOGENS WHERE ENVIRONMENTIAL SURFACES PLAY A ROLE IN TRANSMISSION
MRSA
VRE
Acinetobacter spp.
Clostridium difficile
Norovirus
Rotavirus
SARS
ENVIRONMENTAL SURVIVALOF KEY PATHOGENS
Pathogen Survival Environmental Data
MRSA Days to weeks 2-3+
VRE Days to weeks 3+
Acinetobacter Days to weeks 2-3+
C. difficile Months (spores) 3+
Norovirus Days to weeks 3+
Adapted from Hota B, et al. Clin Infect Dis 2004;39:1182-9 andKramer A, et al. BMC Infectious Diseases 2006;6:130
Environmental Surface Disinfection
Product and Practice
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Decreasing Order of Resistance of Microorganisms to Disinfectants/Sterilants
Prions
Spores (C. difficile)
Mycobacteria
Non-Enveloped Viruses (norovirus)
Fungi
Bacteria (MRSA, VRE, Acinetobacter)
Enveloped VirusesMost Susceptible
Most Resistant
Proving that Environmental Contamination Leads to Nosocomial Infections
Demonstration of microbial persistence in the environment: In vitrostudies and environmental samples
Demonstration of frequent environmental contamination
Demonstration of HCW hand contamination
Relationship between level of environmental contamination and hand contamination
Demonstration of person-to-person transmission (molecular link)
Demonstration that being housed in a room previously occupied by a patient with the pathogen of interest is a risk factor for disease
Demonstration that improved surface cleaning/disinfection reduces disease incidence
DAZO Solution (AKA – Goo)
Thoroughness of Environmental CleaningCarling and coworkers, SHEA 2010
Mean = 34%
>65,000 Objects
FREQUENCY OF ACQUISITION OF MRSA ON GLOVED HANDS AFTER CONTACT WITH SKIN AND ENVIRONMENTAL SITES
No significant difference on contamination rates of gloved hands after contact with skin or environmental surfaces (40% vs 45%; p=0.59), that is,touching the environment results in hand/glove contamination
Stiefel U, et al. ICHE 2011;32:185-187
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Risk of Acquiring MRSA, VRE, and C. difficilefrom Prior Room Occupants
Admission to a room previously occupied by an MRSA-positive patient or VRE-positive patient significantly increased the odds of acquisition for MRSA and VRE (although this route is a minor contributor to overall transmission). Huang et al. Arch Intern Med 2006;166:1945.
Prior environmental contamination, whether measured via environmental cultures or prior room occupancy by VRE-colonized patients, increases the risk of acquisition of VRE. Drees et al. Clin Infect Dis 2008;46:678.
Prior room occupant with CDAD is a significant risk for CDAD acquisition. Shaughnessy et al. ICHE 2011:32:201
Reduction in Acquisition of VRE after Enforcement of Routine Environmental Cleaning Measures
Hayden et al. Clin Infect Dis 2006;42:1552
Acquisition of VRE decreased significantly after baseline and remained stable; when environmental cleaning was significantly improved in periods 2-4. Adherence to hand hygiene increased in period 2 but high adherence did not persist and lowest in period 3. Thus, environmental cleaning was considered to be the sole intervention.
Acinetobacter
ACINETOBACTER AS AHOSPITAL PATHOGEN
Gram-negative aerobic bacillus Common nosocomial pathogen; outbreaks of MDR Acinetobacter Pathogenic: High attributable mortality (Falagas M, et al. Crit Care
2007;11:134) Hospitalized patients: 8-23% ICU patients: 10-43%
Ubiquitous in nature and hospital environment Found on healthy human skin Found in the environment
Survives in the environment for a prolonged period of time Often multidrug resistant
Prevalence of Acinetobacter in Device-Related HAIs, NHSN, 2006-2007
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
Overall CRA-BSA CR-UTI VAP SSI
#9 #9#9
#3
#9
Acinetobacter Contaminationof the Environment
Acinetobacter isolated from curtains, slings, patient-lift equipment, door handles, and computer keyboards (Wilks et al. ICHE 2006;27:654)
A. baumannii isolated from 3% of 252 environmental samples: 2/6 stethoscopes, 1/12 patient records, 4/23 curtains, 1/23 OR lights (Young et al. ICHE 2007;28:1247)
A. baumannii isolated from 41.4% of 70 environmental cultures: 9 headboards, 2 foot of bed, 6 resident desks, 8 external surface ET tube (Markogiannakis et al. ICHE 2008;29:410)
Acinetobacter isolated from environmental surfaces on 2 occasions (Shelburne et al. J Clin Microbiol 2008;46:198)
A. baumannii isolated from 21 environmental samples: 4 ventilator surfaces, 4 bedside curtains, 1 bed rail (Chang et al. ICHE 2009;30:34)
CRAB-isolated from 24/135 (17.9%) environmental samples and 7/65 (10.9%) of HCWs; genetically related (Choi et al. JKMS 2010;25:999)
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Frequency of Contamination of Gowns, Gloves and Hands of HCPs after Caring for Patients
77 (38.7%) resulted in HCW contamination of gloves and/or gowns and 9 (4.5%) resulted in hand contamination after glove removal and before HH. That is, gloves/hands become contaminated with Acinetobacter after caring for patients.
A. baumannii Survival on Dry Surfaces
Environmental survival (Jawad et al. J Clin Microbiol 1998;36:1938)
27.29 days, sporadic strains
26.55 days, outbreak strains
A. baumannii Survival on Dry Surfaces
Environmental survival (Sheifert et al. J Clin Microbiol 1998;36:1938)
27.29 days, sporadic strains
26.55 days, outbreak strains
Jawas et al. JHI 1998;39:235
Transmission of Acinetobacter
Dijkshoorn L, et al.Nature Rev Microbiol 2007;5:939-951
Control Measures
Reemphasis of hand hygiene Practice of sterile technique for all invasive procedures Cleaning the environment of care (including equipment) Contact Precautions (donning gowns and gloves) Enhanced infection control measures: cohorting of
patients with cohorting of staff; use of dedicated patient equipment; surveillance cultures; enhanced environmental cleaning; covert observations of practice; educational modules; disinfection of shared patient equipment
Norovirus
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Bronson Elementary SchoolNorwalk, Ohio
Dr. Al Kapikian, NIH
EM Scope used to discover Norwalk virus in 1972
©
The Discovery of Norwalk VirusNOROVIRUS:
MICROBIOLOGY AND EPIDEMIOLOGY
Classified as a calicivirus: RNA virus, non-enveloped Prevalence
Causes an estimated 23 million infections per year in the US Results in 50,000 hospitalizations per year (310 fatalities) Accounts for >90% of nonbacterial and ~50% of all-cause epidemic
gastroenteritis
Infectious dose: 10-100 viruses (ID50 = 18 viruses) Fecal-oral transmission (shedding for up to 2-3 weeks)
Direct contact and via fomites/surfaces; food and water
Droplet transmission? (via ingestion of airborne droplets of virus-containing particles)
HA outbreaks involve patients and staff with high attack rates
Factors Leading to Environmental Transmission of Norovirus
Stable in the environment
Low inoculating dose
Frequent contamination of the environment
Susceptible population (limited immunity)
Relatively resistant to disinfectants
Common source of infectious gastroenteritis
Primary Modes of Transmission of Norovirus Outbreaks England & Wales 1992-2000
Setting of Outbreak Foodborne* Person-to-Person*
Other / Unknown*
No*
Hospital 10 (1.3) 716 (95.0) 28 (3.7) 754
Residential facilities 33 (4.5) 658 (91.0) 32 (4.4) 723
School 4 (5.5) 65 (89.0) 4 (5.5) 73
Food Outlet 70 (66.7) 23 (21.9) 12 (11.4) 105
Hotel 42 (28.6) 94 (63.9) 11 (7.5) 147
Other 25 (33.8) 43 (58.1) 6 (8.1) 74
Total 184 (9.9) 1599 (85.2) 93 (5.0) 1877
* number of outbreaks (% of all outbreaks in setting)
Hospital Outbreaks
Attack rate: 62% (13/21) for patients and 46% (16/35) for staff (Green et al. J Hosp Infect 1998;39:39)
Number ill: 77 persons (28 patients and 49 staff) (Leuenberger et al. Swiss Med Weekly 2007;137:57)
Attack rate: 21% (20 of 92) of all patients admitted to the pediatric oncology unit (Simon et al. Scand J Gastro 2006;41:693)
Attack rate: 75% (3 of 4) of patients and 26% (10 of 38) staff (Weber et al. ICHE 2005;26:841)
Environmental Contamination
Hospital-11/36 (31%) environmental swabs were positive by RT-PCR. Positive swabs were from lockers, curtains and commodes and confined to the immediate environment of symptomatic patients (Green et al. J Hosp Infect 1998;39:39)
Rehabilitation Center-Norovirus detected from patients and three environmental specimens (physiotherapy instrument handle, toilet seat [2-room of symptomatic guest, public toilet]) RT-PCR (Kuusi et al. Epid Infect 2002;129:133-138)
LTCF-5/10 (50%) of the environmental samples were positive for norovirus by RT-PCR (Wu et al. ICHE 2005;26:802)
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Environmental Survival
At 20oC a 9-log10 reduction of FCV between 21-28 days in a dried state (Doultree et al. J Hosp Infect 1999;41:51)
HuNV was detected by RT-PCR on stainless steel, ceramic, and formica surfaces for 7 days (D’Souza D et al. Int J Food Microbiol 2006;108:84-91)
MNV survived more than 40 days on diaper material, on gauze, and in a stool suspension (JungEun L et al. Appl Environ Microbiol 2008;74:2111-17)
FCV can survive up to 3 days on telephone buttons and receivers, 1-2 days on a computer mouse, and 8-12 hours on a keyboard (Clay S et al. AJIC 2006;34:41-3)
FCV, feline calicivirus; HuNV, human norovirus; MNV, mouse norovirus
Role of the Environment
1. Prolonged outbreaks on ships suggest norovirus survives well2. Outbreak of GE affected more than 300 people who attended a
concert hall over a 5-day period. Norwalk-like virus (NLV) confirmed in fecal samples by RT-PCR. The index case was a concert attendee who vomited in the auditorium. GI illness occurred among members of 8/15 school parties who attended the following day. Disinfection procedure was poor. Evans et al. Epid Infect 2002;129:355
3. Extensive environmental contamination of hospital wardsStudies suggest transmission most likely occurred through direct contact with contaminated fomites.
Surface Disinfection
School outbreak of NLV-cleaning with QUAT preparations made no impact on the course of the outbreak. The outbreak stopped after the school closed for 4 days and was cleaned using chlorine-based agents (Marks et al. Epid Inf 2003;131:727)
Detergent-based cleaning to produce a visibly clean surface consistently failed to eliminate norovirus contamination. A hypochlorite/detergent formulation of 5,000 ppm chlorine was sufficient to decontaminate surfaces. (Barker et al. J Hosp Infect 2004;58:42)
Inactivation of Murine and Human Norovirus
Disinfectant, 1 min MNV Log10 Reduction HNV Log10 Reduction
70% Ethanol >4 (3.3 at 15sec) 2
70% Isopropyl alcohol 4.2 2.2
65% Ethanol + QUAT >2 3.6
79% Ethanol + QUAT 3.4 3.6
Chlorine (5,000ppm) 4 3
Chlorine (24,000ppm) 2.4 4.3
Phenolic, QUAT, Ag, 3% H202 <1 <1 (2.1 QUAT)
0.5% Accel H202 3.9 2.8
Rutala WA, Folan MP, Tallon LA, Lyman WH, Park GW, Sobsey MD, Weber DJ. 2007
Inactivation of Murine and Human Norovirus
Antiseptic, 1 min MNV Log10 Reduction HNV Log10 Reduction
Ethanol Hand Spray 3.2 0.4
Ethanol Based Rub 1.9 2.1
Iodophor (10%) 0.8 0.5
4% CHG 0.1 0.3
0.5% Triclosan 1.3 0.2
1% PCMX 0 2.4
Guideline for the Prevention of Norovirus Outbreaks in Healthcare, HICPAC, 2011
Avoid exposure to vomitus or diarrhea. Place patients with suspected norovirus on Contact Precautions in a single room (lB) Continue Precautions for at least 48 hours after symptom resolution (lB) Use longer isolation times for patients with comorbidities (ll) or <2 yrs (ll)
Consider minimizing patient movements within a ward (ll) Consider restricting movement outside the involved ward unless essential (ll) Consider closure of wards to new admissions (ll)
Exclude ill personnel (lB) During outbreaks, use soap and water for hand hygiene (lB) Clean and disinfect patient care areas and frequently touched surfaces
during outbreaks 3x daily using EPA approved healthcare product (lB) Clean surfaces and patient equipment prior to disinfection. Use product
with an EPA approved claim against norovirus (lC)
MacCannell T, et al. http://www.cdc.gov/hicpac/pdf/norovirus/Norovirus-Guideline-2011.pdf
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C. difficile
C. difficile: Microbiology and Epidemiology
Gram-positive bacillus: Strict anaerobe, spore-former
Colonizes human GI tract
Increasing prevalence and incidence
New epidemic strain that hyperproduces toxins A and B
Introduction of CDI from the community into hospitals
High morbidity and mortality in elderly
Inability to effectively treat fulminant CDI
Absence of a treatment that will prevent recurrence of CDAD
Inability to prevent CDAD
From McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15 and unpublished CDC data
0
20
40
60
80
100
120
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Dis
char
ges
per 1
00,0
00 p
opul
atio
n
Any diagnosisPrimary
Rates of C. difficile Disease in U.S. Hospitals, 2000 - 2005
CDI Now the Most Common Healthcare-Associated Pathogen
Analysis of 10 community hospitals, 2005-2009, in the Duke DICON system
Miller BA, et al. ICHE 2011;32:387-390
Factors Leading to Environmental Transmission of C. difficile
Stable in the environment
Low inoculating dose
Common source of infectious gastroenteritis
Frequent contamination of the environment
Susceptible population (limited immunity)
Relatively resistant to disinfectants
Environmental Contamination
25% (117/466) of cultures positive (<10 CFU) for C. difficile. >90% of sites positive with incontinent patients. (Samore et al. AJM 1996;100:32)
31.4% of environmental cultures positive for C. difficile. (Kaatz et al. AJE 1988;127:1289)
9.3% (85/910) of environmental cultures positive (floors, toilets, toilet seats) for C. difficile. (Kim et al. JID 1981;143:42)
29% (62/216) environmental samples were positive for C. difficile. 29% (11/38) positive cultures in rooms occupied by asymptomatic patients and 49% (44/90) in rooms with patients who had CDAD. (NEJM 1989;320:204)
10% (110/1086) environmental samples were positive for C. difficile in case-associated areas and 2.5% (14/489) in areas with no known cases. (Fekety et al. AJM 1981;70:907)
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PERCENT OF STOOL, SKIN, AND ENVIRONMENT CULTURES POSITIVE FOR C. difficile
Skin (chest and abdomen) and environment (bed rail, bedside table, call button, toilet seat)Sethi AK, et al. ICHE 2010;31:21-27
FREQUENCY OF ENVIRONMENTAL CONTAMINATION AND RELATION TO HAND CONTAMINATION
Study design: Prospective study, 1992 Setting: Tertiary care hospital Methods: All patients with CDI assessed with
environmental cultures Results
Environmental contamination frequently found (25% of sites) but higher if patients incontinent (>90%)
Level of contamination low (<10 colonies per plate)
Also contaminated: BP cuff, electronic thermometer, IV accurate control device and oximeter
↑ hand cont ↑ surface cont
Samore MH, et al. Am J Med 1996;100:32-40
PERSISTENCE OF CLINICALLY RELEVANT BACTERIA ON DRY INANIMATE SURFACES
Kramer A, et al. BMC Infect Dis 2006;6:130
EVALUATION OF HOSPITAL ROOM ASSIGNMENT AND ACQUISITION OF CDI
Study design: Retrospective cohort analysis, 2005-2006
Setting: Medical ICU at a tertiary care hospital
Methods: All patients evaluated for diagnosis of CDI 48 hours after ICU admission and within 30 days after ICU discharge
Results (acquisition of CDI) Admission to room previously
occupied by CDI = 11.0% Admission to room not previously
occupied by CDI = 4.6% (p=0.002)
Shaughnessy MK, et al. ICHE 2011;32:201-206
Disinfectants and AntisepticsC. difficile spores at 10 and 20 min, Rutala et al, 2006
~4 log10 reduction (5 C. difficile strains including BI-9) Clorox, 1:10, ~6,000 ppm chlorine (but not 1:50,
~1,200 ppm) Clorox Clean-up, ~19,100 ppm chlorine Tilex, ~25,000 ppm chlorine Steris 20 sterilant, 0.2% peracetic acid Cidex, 2.4% glutaraldehyde Cidex-OPA, 0.55% OPAWavicide, 2.65% glutaraldehyde Aldahol, 3.4% glutaraldehyde and 26% alcohol
DISINFECTANTSNo measurable activity (1 C. difficile strain, J9; spores at 20 min)
Vesphene (phenolic) 70% isopropyl alcohol 95% ethanol 3% hydrogen peroxide Clorox disinfecting spray (65% ethanol, 0.6% QUAT) Lysol II disinfecting spray (79% ethanol, 0.1% QUAT) TBQ (0.06% QUAT); QUAT may increase sporulation capacity-
(Lancet 2000;356:1324)
Novaplus (10% povidone iodine) Accel (0.5% hydrogen peroxide)
Rutala W, Weber D, et al. 2006
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Environmental Surface Disinfection
Product-5000-6000ppm chlorine effective (or another sporicidal product)
Effect of Hypochlorite on Environmental Contamination and Incidence of C. difficile
Use of chlorine (500-1600 ppm) decreased surface contamination and the outbreak ended. Mean CFU/positive culture in outbreak 5.1, reduced to 2.0 with chlorine. (Kaatz et al. Am J Epid 1988;127:1289)
In an intervention study, the incidence of CDAD for bone marrow transplant patients decreased significantly, from 8.6 to 3.3 cases per 1000 patient days after the environmental disinfection was switched from QUAT to 1:10 hypochlorite solution in the rooms of patients with CDAD. No reduction in CDAD rates was seen among NS-ICU and medicine patients for whom baseline rates were 3.0 and 1.3 cases per 1000-patient days. (Mayfield et al. Clin Inf Dis 2000;31:995)
Effect of Hypochlorite on Environmental Contamination and Incidence of C. difficile
35% of 1128 environmental cultures were positive for C. difficile. To determine how best to decontaminate, a cross-over study conducted. There was a significant decrease of C. difficile on one of two medicine wards (8.9 to 5.3 per 100 admissions) using hypochlorite (1,000 ppm) vs. detergent. (Wilcox et al. J Hosp Infect 2003;54:109)
Acidified bleach (5,000 ppm) and the highest concentration of regular bleach tested (5,000 ppm) could inactivate all the spores in <10 minutes. (Perez et al. AJIC 2005;33:320)
PROVING THAT ENVIRONMENTAL CONTAMINATION IMPORTANT IN C. difficile TRANSMISSION
Environmental persistence (Kim et al. JID 1981;14342)
Frequent environmental contamination (McFarland et al. NEJM 1989;320:204)
Demonstration of HCW hand contamination (Samore et al. AJM 1996;100:32)
Environmental hand contamination (Samore et al. AJM 1996;100:32)
Person-to-person transmission (Raxach et al. ICHE 2005;26:691))
Transmission associated with environmental contamination (Samore et al. AJM 1996;100:32)
CDI room a risk factor (Shaughnessy et al. IDSA/ICAAC. Abstract K-4194)
Improved disinfection epidemic CDI (Kaatz et al. AJE 1988;127:1289)
Improved disinfection hyperendemic CDI (Boyce et al. ICHE 2008;29:723)
Evidence Supporting the Role of Environmental Contamination in Transmission of CDI
C. difficile is able to survive for prolonged periods in the environment Environmental contamination is frequently found in the rooms of infected
patients Contaminated environmental reservoirs have been demonstrated to be the source
of an outbreak Contamination of healthcare personnel hands has been demonstrated Levels of environmental contamination are associated with the frequency of
healthcare personnel hand contamination Prevalence of environmental contamination has been associated with the
incidence of patient acquisition and infection Admission to a room previously occupied by an infected patient is associated
with the risk of colonization or infection Environmental cleaning and disinfection has been demonstrated to reduce the
hospital incidence of CDIWeber DJ, Rutala WA. ICHE 2011;32:207-209
CLINICAL PRACTICE GUIDELINES FOR C. difficile, SHEA & IDSA, 2010
HCWs and visitors must use gloves (AI) and gowns (BIII) on entry to room
Emphasize compliance with the practice of hand hygiene (AII)
In a setting in which there is an outbreak or an increased CDI rate, instruct visitors and HCP to wash hands with soap (or antimicrobial soap) and water after caring for or contacting patients with CDI (BIII)
Accommodate patients with CDI in a private room with Contact Precautions (BIII)
Maintain Contact Precautions for the duration of diarrhea (CIII)
Identification and removal of environmental sources of C. difficile, including replacement of electronic rectal thermometers with disposables, can reduce the incidence of CDI (BII)
Use chlorine containing cleaning agents or other sporicidal agents in areas with increased rates of CDI (BII)
Routine environmental screening for C. difficile is NOT recommended (CIII)
Cohen SH, et al. ICHE 2010;31:431-435
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UNC HEALTH CARE ISOLATION SIGN FOR PATIENTS WITH NOROVIRUS OR C. difficile
Use term Contact-Enteric Precautions
Requires gloves and gown when entering room
Recommends hand hygiene with soap and water (instead of alcohol-based antiseptic)
Information in English and Spanish
Role of Hospital Surfaces in TransmissionSummary
Contaminated environment likely important for Acinetobacter, norovirus, and C. difficile
Supportive data include: prior room occupant with pathogen a significant risk for acquisition; an improved surface cleaning/disinfection reduces disease incidence
Adhere to proper room cleaning and disinfection protocols which may include monitoring, new methods for room decontamination and practice improvements (checklist, assignments, education)
Role of Surfaces
Factors that facilitate environmental transmission Acinetobacter
Norovirus
C. difficile
Thank you